AHS:AAN guidelines for prevention of episodic migraine 2012

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AHS:AAN guidelines for prevention of episodic migraine 2012


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  • 1. Research Submissions The 2012 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison With Other Recent Clinical Practice Guidelineshead_2185 930..945 Elizabeth Loder, MD, MPH; Rebecca Burch, MD; Paul Rizzoli, MD Background.—Updated guidelines for the preventive treatment of episodic migraine have been issued by the American Headache Society (AHS) and the American Academy of Neurology (AAN). We summarize key 2012 guideline recommenda- tions and changes from previous guidelines. We review the characteristics, methods, consistency, and quality of the AHS/AAN guidelines in comparison with recently issued guidelines from other specialty societies. Methods.—To accomplish this, we reviewed the AHS/AAN guidelines and identified comparable recent guidelines through a systematic MEDLINE search. We extracted key data, and summarized and compared the key recommendations and assessed quality using the Appraisal of Guidelines Research and Evaluation-II (AGREE-II) tool. We identified 2 additional recent guidelines for migraine prevention from the Canadian Headache Society and the European Federation of Neurological Societies. All of the guidelines used structured methods to locate evidence and linked recommendations with assessment of the evidence, but they varied in the methods used to derive recommendations from that evidence. Results.—Overall, the 3 guidelines were consistent in their recommendations of treatments for first-line use. All rated topiramate, divalproex/sodium valproate, propranolol, and metoprolol as having the highest level of evidence. In contrast, recommendations diverged substantially for gabapentin and feverfew. The overall quality of the guidelines ranged from 2 to 6 out of 7 on the AGREE-II tool. Conclusion.—The AHS/AAN and Canadian guidelines are recommended for use on the basis of the AGREE-II quality assessment. Recommendations for the future development of clinical practice guidelines in migraine are provided. In particular, efforts should be made to ensure that guidelines are regularly updated and that guideline developers strive to locate and incorporate unpublished clinical trial evidence. Key words: migraine, guidelines, prevention, prophylaxis, quality, AGREE-II (Headache 2012;52:930-945) INTRODUCTION The American Headache Society (AHS) and the AmericanAcademy of Neurology (AAN) have issued updated guidelines for pharmacologic preventive treatment of episodic migraine.1,2 Migraine is a common, disabling, and costly disorder. There is no cure, but preventive treatment to decrease the number and severity of headache attacks improves health outcomes and quality of life.3 It also reduces disability and costs.4From the Graham Headache Center and the Department of Neurology, Division of Headache and Pain, Brigham and Women’s and Faulkner Hospitals, Boston, MA, USA (E. Loder, R. Burch, P. Rizzoli). Address all correspondence to E. Loder, Department of Neu- rology, Brigham and Women’s Hospital, 1153 Centre Street, Boston, MA 02130, USA, email: eloder@partners.org To download a podcast featuring further discussion of this article, please visit www.headachejournal.org Accepted for publication April 23, 2012. Conflict of Interest: PR and RB have no conflicts of interest relevant to this paper. EL is a member of the dissemination committee for the 2012 AHS/AAN Guidelines but was not involved in their development. She is the president-elect of the American Headache Society, which was a partner in the development of the guidelines and endorsed the completed guidelines. Financial support for work: None. ISSN 0017-8748 doi: 10.1111/j.1526-4610.2012.02185.x Published by Wiley Periodicals, Inc. Headache © 2012 American Headache Society 930
  • 2. The AHS/AAN guidelines are the result of a systematic search, expert review, and synthesis of rel- evant evidence for preventive treatments of episodic migraine. The evidence identified in formulating the previous guidelines in 2000 was supplemented with evidence from a new search that extended through mid 2009. Despite the availability of such up-to-date, evidence-based recommendations, research suggests that a majority of migraine sufferers who would benefit from prevention therapies do not receive them.5,6 Possible barriers to the adequate preventive treatment of migraine may be lack of physician awareness of the contents of clinical practice guide- lines or a lack of confidence in the methodology and quality of such guidelines.7-9 Variability in guideline quality and consistency has been demonstrated in other therapeutic areas.10-12 One recent study on clini- cal practice guideline quality concluded that the quality of clinical practice guidelines improved only slightly over the past 2 decades.13 We sought to summarize the key recommenda- tions of the 2012 AHS/AAN guidelines and identify areas of change from the 2000 guidelines that they replace. In addition, we systematically review the quality and consistency of these guidelines in com- parison with 2 other recent migraine prevention clinical practice guidelines. METHODS All authors read the 2012 AHS/AAN guidelines for migraine prevention, and EL summarized key concepts and changes from the 2000 guidelines.These were reviewed with PR and RB, and agreement on the summary was reached by consensus. Although these guidelines were published as 2 separate papers, 1 covering traditional pharmacologic agents for migraine prophylaxis and the other covering non-steroidal anti-inflammatory drugs (NSAIDs), complementary treatments and other miscellaneous treatments, for the purposes of this review, we consider the guidelines as a whole and refer to the contents of the 2 documents as “the AHS/AAN guidelines.”Although the 2012 guidelines incorporate drugs used for short-term prophylaxis of menstrually triggered migraine attacks among the other treat- ments, for this review, we consider them separately to facilitate comparison with other guidelines, which generally do not consider such short-term treatments to be comparable with daily, long-duration preventive treatment. An additional caveat, conspicuous by its absence from the guidelines presented here is onabotulinum- toxinA. OnabotulinumtoxinA has been extensively studied for treatment of episodic migraine and found to be ineffective. It was not included in the current AHS/AAN guidelines for preventive treatment of episodic migraine because it is covered in another AAN guideline, where it is identified as ineffective for episodic migraine. OnabotulinumtoxinA was, however,approved by the Food and DrugAdministra- tion for the treatment of chronic migraine in October 2010, and at this writing is the only treatment specifi- cally indicated for that migraine variant. Its exclusion reflects simply that the guidelines we review and sum- marize pertain to the treatment of episodic migraine (ie, migraine with a headache burden of <15 days/ month).A discussion of chronic migraine and its treat- ment would be timely (and clinically relevant) but lies beyond the scope of the present paper. For the systematic review portion of this study,we searched for clinical practice guidelines for the pre- ventive treatment of migraine in adults 18 or older. We included only guidelines based on a systematic review and synthesis of evidence, and graded recom- mendations linked to evidence quality. Guidelines had to be written in English and endorsed by a national or international professional organization. We excluded guidelines that focused solely on the treatment of specific subgroups of migraineurs, eg, pregnant women or children. To ensure that the clinical practice guidelines included in this review are relevant to contemporary medical practice, inclusion was limited to guidelines published from January 2008 through April 2012. We searched MEDLINE from January 2008 to April 2012 using the text words and Medical Subject Heading terms of “migraine” and “guidelines.” The electronic database search was supplemented by searching websites that list guidelines. The search strategy is contained in Appendix II. EL screened the search results for inclusion. Full-text papers were Headache 931
  • 3. retrieved for potentially relevant clinical practice guidelines and reviewed against inclusion criteria. The included clinical practice guidelines were sum- marized descriptively by EL and reviewed by RB according to pharmacologic and other preventive treatment options. For each treatment, we noted whether the respective guideline recommended that treatment, the level of evidence assigned to it, and the appraised quality of studies supporting the recommendation. We compared treatment ratings among the included guidelines. Because each guideline used dif- ferent methods to rate and assign treatments to cat- egories, we assumed that the top tier in each rating system was comparable with the top tier in the other guidelines, and so on.Thus, Level A in the AHS/AAN guidelines was considered equivalent to the “High” level of evidence category in the Canadian guidelines (regardless of the strength of the recommendation to use or not use, which was based on judgments about the balance of harms to benefits) and the “drugs of first choice”category in European Federation of Neu- rological Societies (EFNS). Similarly, Level B was considered equivalent to the “Moderate” level of evi- dence category in the Canadian guidelines and the “drugs of second choice” category in the EFNS guide- lines.Finally,Level C in theAHS/AAN guidelines was considered equivalent to the “Low” level of evidence category in the Canadian guidelines and to the “drugs of third choice” category in the EFNS guidelines. All authors independently scored retrieved guidelines according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. The AGREE criteria are widely used to assess the quality of clinical practice guidelines. They provide a list of specific information that should be reported in guideline publications. Specifically, the AGREE-II assessment instrument contains 23 items distributed among 6 quality domains, along with 2 global quality ratings.14 The 6 domains and the guideline characteristics assessed within each domain are: (1) Scope and Purpose, which assesses the overall aim of the guide- line and target groups for whom the guideline is intended; (2) Stakeholder Involvement, which evalu- ates the extent to which appropriate stakeholders were involved in developing the guideline and whether it represents the views of its intended users; (3) Rigor of Development, which appraises the process of gathering and summarizing the evidence and methods used to develop recommendations; (4) Clarity of Presentation, which evaluates the language, structure, and format of the guideline; (5) Applicabil- ity, which evaluates potential barriers and facilitators to implementation and strategies to improve uptake as well as resources needed to implement the guide- line; and (6) Editorial Independence, which evaluates biases because of competing interests. The overall assessment includes rating the overall quality of the guideline and stating whether the guideline is recom- mended for use in practice. Each item within a domain is rated on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree). A score of 1 indicates that there is no infor- mation on that item or that it is very poorly reported. A score of 7 indicates that criteria for the item delin- eated in the AGREE-II user manual have been met and that the reporting is complete and clear.A quality score for each of the 6 domains is calculated, in addition to a global assessment of overall guideline quality and recommendations for clinical use. The AGREE-II developers recommend that guideline quality should be assessed by 2-4 reviewers. RESULTS Summary of AHS/AAN Migraine Prevention Guideline Recommendations.—Tables 1–3 summa- rize key recommendations of the AHS/AAN 2012 guidelines for preventive treatment of migraine. The new guidelines assign treatments to 1 of 5 levels based on the strength of evidence for their efficacy: Level A, Level B, Level C, Level U, and an “Other” group.The last contains drugs that are established as, or probably or possibly ineffective. This method of categorizing treatments is based entirely on assessments of the strength of scientific evidence of drug efficacy and does not incorporate evidence about side effects or qualitative clinical impressions. This differs from the method used to classify treat- ments in the 2000 guidelines.15 In the 2000 guidelines, treatments were assigned to 1 of 5 groups,with group 1 indicating the highest level of recommendation and 932 June 2012
  • 4. group 5 the lowest. The group assignment, however, was based on a combination of the quality of clinical trial evidence but also incorporated clinical judgments of efficacy and evidence concerning potential adverse effects.This change in rating method should be borne in mind when the reader compares the ratings of drugs between the 2 guidelines. Level A Drugs.—Three beta-blockers (meto- prolol, propranolol, and timolol), several anti- epileptic drugs (topiramate, and divalproex or sodium valproate), as well as the herbal drug Butterbur are rated as Level A drugs in the 2012 guidelines. This rating is given to treatments for which there are at least 2 high-quality randomized, controlled trials (RCTs) demonstrating efficacy.The guideline authors suggest that Level A drugs should be offered to patients who require prophylaxis for migraine. In the 2000 guidelines, only 4 drugs were placed in group 1: amitriptyline, divalproex, propranolol, and timolol. Of note, 3 of those 4 drugs retain the highest rating in Table 1.—AHS/AAN Migraine Prevention Guidelines Drugs Recommended for Use Drug Examples of Studied Doses Level A: established as effective Should be offered to patients requiring migraine prophylaxis Divalproex/sodium valproate 400-1000 mg/day Metoprolol 47.5-200 mg/day Petasites (butterbur) 50-75 mg bid Propranolol 120-240 mg/day Timolol 10-15 mg bid Topiramate 25-200 mg/day Level B: probably effective Should be considered for patients requiring migraine prophylaxis Amitriptyline 25-150 mg/day Fenoprofen 200-600 mg tid Feverfew 50-300 mg bid; 2.08-18.75 mg tid for MIG-99 preparation Histamine 1-10 ng subcutaneously twice a week Ibuprofen 200 mg bid Ketoprofen 50 mg tid Magnesium 600 mg trigmagnesium dicitrate qd Naproxen/naproxen sodium 500-1100 mg/day for naproxen 550 mg bid for naproxen sodium Riboflavin 400 mg/day Venlafaxine 150 mg extended release/day Atenolol 100 mg/day Level C: possibly effective May be considered for patients requiring migraine prophylaxis Candesartan 16 mg/day Carbamazepine 600 mg/day Clonidine 0.75-0.15 mg/day; patch formulations also studied Guanfacine 0.5-1 mg/day Lisinopril 10-20 mg/day Nebivolol 5 mg/day Pindolol 10 mg/day Flurbiprofen 200 mg/day Mefenamic acid 500 mg tid Coenzyme Q10 100 mg tid Cyproheptadine 4 mg/day Based on Silberstein et al2 and Holland et al.1 Studied dose information abstracted from these guidelines and Agency for Health Care Policy and Research technical review (http://www.ncbi.nlm.nih.gov/books/NBK45457/pdf/TOC.pdf). Intended solely to give an idea of tested doses and not as a recommendation for treatment. All drugs given orally unless otherwise noted. AAN = American Academy of Neurology; AHS = American Headache Society; bid = twice a day; qd = daily; tid = 3 times a day. Headache 933
  • 5. the updated guidelines.Amitriptyline has been down- graded to Level B in the new guidelines. Level B Drugs.—The 2012 AHS/AAN guidelines assign 10 drugs to Level B, which is reserved for treat- ments for which there is only 1 high-quality RCT, or 2 or more less rigorous studies suggesting efficacy. The guideline authors suggest that Level B drugs should be considered for patients who require prophylaxis Table 2.—AHS/AAN Migraine Prevention Guidelines Drugs Recommended for Short-Term Prevention of Migraine Associated With Menstruation Drug Dose or Dose Range Comment Level A: established as effective Should be offered to patients requiring prophylaxis Frovatriptan 2.5 mg bid perimenstrually A loading dose was used Level B: probably effective Should be considered for patients requiring prophylaxis Naratriptan 1 mg bid for 5 days perimenstrually No loading dose Zolmitriptan 2.5 mg bid or tid perimenstrually No loading dose Level C: possibly effective May be considered for patients requiring prophylaxis Estrogen 1.5 mg estradiol in gel qd ¥ 7 days perimenstrually Based on Silberstein et al2 and Holland et al.1 Studied dose information abstracted from these guidelines and intended solely to give an idea of tested doses and not as a recommendation for treatment. All drugs given orally unless otherwise noted. AAN = American Academy of Neurology; AHS = American Headache Society; bid = twice a day; qd = daily; tid = 3 times a day. Table 3.—AHS/AAN Migraine Prevention Guidelines Drugs and Treatments With Conflicting or Inadequate Evidence of Efficacy or With Evidence Indicating Lack of Efficacy Drug or Treatment Level U: conflicting or inadequate evidence Insufficient data to support or refute use for migraine prophylaxis Acenocoumarol Hyperbaric oxygen Acetazolamide Indomethacin Aspirin Nicardipine Bisoprolol Nifedipine Coumadin Nimodipine Cyclandelate Omega-3 Fluoxetine Picotamide Fluvoxamine Proptriptyline Gabapentin Verapamil Medications or treatments established as possibly or probably ineffective for migraine prophylaxis Should not be offered or considered for migraine prophylaxis† Acebutolol Montelukast Clomipramine Nabumetone Clonazepam Oxcarbazepine Lamotrigine Telmisartan Based on Silberstein et al2 and Holland et al.1 †The evidence supporting designation of a treatment as ineffective was subcategorized as established, probable, or possible. For this chart, we have collapsed those categories. 934 June 2012
  • 6. for migraine. The Level B group includes amitrip- tyline as well as the herbal treatment feverfew,several NSAIDs, riboflavin (vitamin B2), venlafaxine, and subcutaneous histamine. In the 2000 guidelines, 17 drugs were placed in the second highest group (group 2). These included atenolol, metoprolol, nadolol, gabapentin, verapamil, fluoxetine, fenoprofen, ketoprofen, naproxen and naproxen sodium, feverfew, magnesium, and vitamin B2. In contrast with the drugs in the highest rating category in 2000, there has been considerable change in the ratings assigned to drugs in the former group 2. Roughly 50% of them have been upgraded or downgraded. For example, gabapentin, verapamil, and fluoxetine are assigned to Level U in the 2012 guidelines, a substantial downgrade from their former rating that indicates a changed assessment of the quality or the inclusion of new evidence for these drugs.At least for gabapentin, this judgment is in line with recent evidence that has surfaced of serious problems with the reporting of clinical trial results.16 In contrast, metoprolol has been upgraded to Level A from its former position in group 2. Level C Drugs.—The 2012 AHS/AAN guidelines assign 11 drugs to Level C, which contains drugs for which there is a single less rigorous study indicating efficacy. The guideline authors suggest that Level C treatments “may” be considered for patients requir- ing migraine prophylaxis. Level C includes 2 drugs making new appearances in the guidelines: lisinopril and candesartan. It also includes clonidine, cyprohep- tadine, coenzyme Q10, and several NSAIDs. In the 2000 guidelines, 16 drugs were placed in group 3.These included 10 drugs that are not listed in the updated 2012 guidelines: buproprion, doxepin, imipramine, mirtazapine, nortriptyline, paroxetine, sertraline,trazodone,diltiazem,and phenelzine.Of the remaining 6 drugs that appeared in group 3 in the 2000 guidelines, 2 (fluvoxamine and protriptyline) have been downgraded to Level U in the 2012 guidelines, while cyproheptadine remains in the roughly compa- rable Level C group, and ibuprofen and venlafaxine have been upgraded to Level B. Thus, only 1 drug in the third tier in 2000 has remained in that tier in 2012. Level U Drugs.—Fourteen drugs are assigned to Level U, a category reserved for treatments that have “insufficient data to support or refute use for migraine prophylaxis.” This may mean that studies were judged to have substantial methodological shortcomings or that there are conflicting results from multiple studies. In addition to gabapentin, vera- pamil, and fluoxetine, this group contains the tricyclic antidepressant proptriptyline and the carbonic anhy- drase inhibitor acetazolamide. Ineffective Drugs.—The 2012 AHS/AAN guide- lines also list 8 medications for which evidence is considered to show that they are established as, or possibly or probably ineffective for migraine prophy- laxis. The authors suggest that these should not be offered or considered for patients requiring migraine prophylaxis. These include the anti-epileptic drug lamotrigine, the leukotriene inhibitor montelukast, oxcarbazepine, and telmisartan. In the 2000 guidelines, 8 drugs were placed in the lowest group 5, 3 of which (indomethacin, nicar- dipine, and nifedipine) now are in Level U in the new guidelines. Three drugs included in group 5 in 2000 have been upgraded to Level C in the current guide- lines (carbamazepine, pindolol, and clonidine), while 2 (clomipramine and clonazepam) are now consid- ered likely to be ineffective. Drugs for Menstrually Triggered Attacks of Migraine.—For short-term prevention of menstrually triggered migraine attacks, frovatriptan is assigned to Level A, and naratriptan and zolmitriptan to Level B, while estrogen is in Level C. Comparison of the 2012 AHS/AAN Migraine Prevention Guidelines With Other Contemporary Migraine Prevention Clinical Practice Guidelines.— Our search and abstract screen identified 5 additional contemporary clinical practice guidelines relevant to migraine prevention in adults and published since 2008. Three were excluded, 2 because they were not published in English and 1 because it did not link recommendations to a formal appraisal of evidence.17-19 The 2 guidelines that met criteria for inclusion in this review were guidelines published in 2012 by the Canadian Headache Society (referred to herein as the “Canadian guidelines”) and guidelines published in 2008 by the EFNS (referred to herein as the “EFNS guidelines”).20,21 Table 4 displays the char- acteristics and methods of the 3 guidelines. Headache 935
  • 7. Table4.—CharacteristicsandMethodsUsedForDevelopingthe3MigrainePreventionClinicalPracticeGuidelines AmericanHeadacheSociety(AHS)/American AcademyofNeurology(AAN)GuidelineCanadianGuideline EuropeanFederationofNeurological Societies(EFNS)Guideline Status(neworupdated)UpdatedNewNew Organization(s)participatingin guidelinedevelopment AAN;AANCanadianHeadacheSocietyEFNS Organization(s)endorsingguidelineAAN;AAN;AmericanOsteopathicAssociationCanadianHeadacheSocietyEFNS Funding/sponsorshipsource(s)AAN;AANCanadianHeadacheSocietyEFNS DatesofsearchBuiltonMEDLINEsearchdoneforpreviousguidelines,updated withinformationfromJune1999throughMay2009 MEDLINE,EMBASE,CochraneLibraryinception-April 2008;UpdatedinJune2011.Searchlimitedto“those agentscommonlyusedinclinicalpractice.”Theyprovide alistoftargetdrugs. “Aliteraturesearchwasperformedusingthereference databasesMEDLINE,ScienceCitationIndex,andthe CochraneLibrary...lastsearchinJanuary2009.”Statesthat “allauthorsperformedanindependentliteraturesearch.” Attemptsreportedtolocateunpublished evidenceorverifyfullstudy reporting?Forexample,searchofthe greyliterature,manufacturer databases,regulatorydocuments,or trialregistries. NoNoNo Studyinclusioncriteria“...randomizedadultpatientswithmigrainetotheagentunder studyoracomparatordrug(includingplacebo)andutilized maskedoutcomeassessment” “...requiredtobeprospective,randomized,double-blind, controlledtrialsofdrugtreatmentsusedtopreventthe occurrenceofmigraineattacks.”Studieshadtoinclude adultswhometacceptedcriteriaformigraineorprovide “sufficientdetail”tosupportamigrainediagnosis. “AllpaperspublishedinEnglish,GermanorFrenchwere consideredwhentheydescribedacontrolledtrialoracase seriesonthetreatmentofatleastfivepatients.Inadditiona reviewbookandtheGermantreatmentrecommendations formigrainewereconsidered.” StudyexclusioncriteriaAssessedforheadachesotherthanepisodicmigraine;assessedacute treatment,auratreatment,nonpharmacologictreatment;used qualityoflife,disabilityornonstandardizedoutcomes;tested drugsnotavailableintheUnitedStates. Excludedstudiesofpatientswithheadache15ormore dayspermonth,transformedmigraine,orchronic tension-typeheadache.Excludedstudiesofagentsnot “commonlyusedinclinicalpractice.” Notexplicitlystated. MethodsofclassifyingtreatmentsAANtherapeuticclassificationofevidencescheme.Eachdrug assignedoneofthefollowingratings TreatmentclassifiedbasedontheGradingof RecommendationsAssessment,Developmentand Evaluation(GRADE)method.Eachdrugwasassigned 1of4levelsofevidence:high,moderate,low,orvery low.Therecommendationwasthenfurthergradedas strongorweakbasedonassessmentofthebalanceof benefitsandharms.Developersnotethatthiscanresult ina“strong”recommendationforatherapythatisonly modestlyeffectiveorhasalowlevelofevidence,ifitis welltoleratedandsafe. “Thedefinitionsoftherecommendationlevelsfollowthe EFNScriteria.”EachdrugassignedaratingofA(“drugsof firstchoice”),B(“drugsofsecondchoice”)...evidenceof efficacybutlesseffectiveormoreside-effectsthanlevelA drugs),orC(“drugsofthirdchoice”),onlyprobableefficacy. LevelA(medicationswithestablishedefficacy,greaterthanorequal to2ClassItrials); LevelB(medicationsareprobablyeffective[3ClassIor2ClassII studies]); LevelC(medicationsarepossiblyeffective[3ClassIIstudies]); LevelU(inadequateorconflictingdatatosupportorrefuteuse);or other(medicationsthatareestablishedaspossiblyorprobably ineffective) Methodsofderivingrecommendations (evidencelinkedwithformal consensusmethod;evidencelinked withinformalconsensusmethod; consensusmethodwithnodetailed description;notdescribed Evidencelinkedwithinformalconsensusmethod:“Atleast2 panelistsindependentlyreviewedeachstudyandratedit... Differencesinratingswereresolvedbyauthorpaneldiscussion.” EvidencelinkedwithinformalconsensusmethodConsensusmethodwithnodetaileddescription Assessedincludedstudiesbasedon disease-specificrecommendationsfor outcomemeasures,trialconduct,and adverseeventreportingrecommended byprofessionalsocietyguidelines Inpart:used50%responderratesasmeasureofsuccessInpartNotstated Yearofpublicationofpreviousversion2000NotapplicableNotapplicable YearplannedfornextupdateNotreported“Atleasteverytwoyears.”“Shouldbeupdatedwithinthreeyears” 936 June 2012
  • 8. All were sponsored, funded, and carried out by professional societies devoted to the study of neurol- ogy or headache. Only the AHS/AAN guidelines, however, were endorsed by other specialty groups. All of the guidelines reported that a systematic search for evidence was conducted, although the dates and breadth of the searches varied. The search for the AHS/AAN guidelines extended only through May 2009, while the search for the Canadian guidelines extends through June 2011. The inclusion and exclusion criteria differed among the guidelines, with the result that the AHS/ ANS guidelines consider a larger number of drugs, while the Canadian guidelines rate only a previously agreed-upon list of medications in common use. All of the guidelines used structured methods to appraise retrieved evidence. None, however, reported making any attempts to identify unpublished or incompletely reported evidence for the treatments reviewed. The 3 guidelines also used different methods of appraising and classifying the evidence that was retrieved. Two of the guidelines mentioned the use of a 50% responder rate as a measure of treatment efficacy, as recommended by International Headache Society clinical trial guidelines for migraine-preventive therapies. None, however, reported basing other assessments of study quality on the disease-specific recommendations for other outcome measures, adverse event reporting, or trial methods that have been developed by professional societies, such as the International Headache Society recommendations about the clinical conduct of pre- ventive trials and adverse event reporting.22,23 As previously mentioned, the 2012 AHS/AAN guidelines assign treatments to Levels based on assess- ment of the strength and quality of evidence of effi- cacy. Adverse effects, contraindications to use, and other clinical considerations are reviewed but are not incorporated in the assignment of drugs to a particular level. In contrast, both the Canadian and EFNS incor- porate an assessment of the balance of benefits and harms for a drug into their categorization schemes. Areas of apparent agreement among the guide- line ratings are summarized in Table 5. These must be interpreted in light of the imperfect correspon- dence among the various categories, as described earlier. It is notable, however, that there is consider- able consensus among the guidelines about drugs that are placed in the highest tier, with divalproex, metoprolol, propranolol, and topiramate assigned to the top category in all 3 of the guidelines. Similarly, all of the guidelines place coenzyme Q10 and linsinopril Table 5.—Areas of Apparent Agreement on Evidence Quality for Drugs Rated by at Least 2 of 3 Migraine Prevention Guidelines AHS/AAN Guidelines Canadian Guidelines EFNS Guidelines Coenzyme Q10 C Strong, low-quality evidence C Divalproex A Weak, high-quality evidence A Flunarazine Not rated Weak, high-quality evidence A Lisinopril C Weak, low-quality evidence C Metoprolol A Strong, high-quality (but not reviewed for guidelines, instead rating based on Cochrane review) A Nadolol B Strong, moderate Not rated Naproxen B Not rated B Pizotifen Not rated Weak, high-quality evidence Not rated Propranolol A Strong, high-quality evidence A Topiramate A Strong, high-quality evidence A Assuming that Level A = high-quality evidence = first-line (A) drugs; Level B = moderate-quality evidence = second-line (B) drugs; Level C = low-quality evidence = third-line (C) drugs; Level U and established as, or possibly or probably ineffective = do not use (no comparable rating in EFNS guidelines). AAN = American Academy of Neurology; AHS = American Headache Society; EFNS = European Federation of Neurological Societies. Headache 937
  • 9. in their third category. Some drugs were rated in only 2 guidelines, and in those cases, there was also concordance for naproxen and nadolol, which were placed in the second tier. Drugs rated by only 1 guide- line are listed in Appendix III. The majority of those were rated in the AHS/AAN guidelines, which cast a wider net for evidence than the Canadian and EFNS guidelines. Table 6 identifies areas of apparent divergence among the guidelines. In general, the divergence is not substantial. For 6 of the 11 treatments (amitrip- tyline, candesartan, magnesium, petasites, riboflavin, and venlafaxine), there is only a difference of a single category up or down for one of the guidelines, while the other 2 guidelines place the drug in similar tiers. For 2 drugs, however, the differences in classification are more substantial. Gabapentin is placed in Level U (conflicting or insufficient evidence to support or refute efficacy) whereas in the 2012 AHS/AAN guidelines, while the Canadian guidelines rate it as having “moderate-quality evidence” and make a strong recommendation for its use based on the combination of possible efficacy and good tolerability. The EFNS guidelines consider it a “third choice” drug. For feverfew, the Canadian guidelines recom- mend against use based on an interpretation of the trial evidence as negative overall, while the AHS/ AAN guidelines include it in Level B (probably effec- tive, should be considered) and the EFNS guidelines consider it a “third choice” treatment. AGREE-II Appraisal Results.—Table 7 shows the results of the quality rating using the AGREE-II tool for assessing clinical practice guideline quality. In general, the Canadian and the AHS/AAN guidelines received higher scores for quality in all domains, with the Canadian guidelines achieving the highest overall assessment of quality. The AHS/AAN guide- lines received their highest score in Domain 1, which scores the reporting of the scope and purpose of the guidelines, and their lowest score in stakeholder involvement, which appraises the extent to which stakeholders such as patients and nonspecialist clini- cians were involved in guideline development. The Canadian guidelines also received their highest score in Domain 1 and their lowest in Domain 6, which rates the reporting of factors associated with editorial independence. The EFNS guidelines had consistently low scores in all domains with the exception of Domain 6, edi- torial independence, where they achieved their highest score. They were rated lowest in Domain 4, Clarity of Presentation. Based on an overall assess- Table 6.—Areas of Apparent Divergence About Evidence Quality for Drugs Rated by at Least 2 Guidelines for Migraine Prevention AHS/AAN Guidelines Canadian Guidelines EFNS Guidelines Amitriptyline B Strong, high-quality evidence B Aspirin U Not rated C Bisoprolol U Not rated B Candesartan C Strong, moderate-quality evidence C Feverfew B Do not use C Gabapentin U Strong, moderate-quality evidence C Magnesium B Strong, low-quality evidence C Petasites A Strong, moderate-quality evidence B Riboflavin B Strong, low-quality evidence C Venlafaxine B Weak, low-quality evidence B Verapamil U Weak, low-quality evidence N/A Assuming that Level A = high-quality evidence = first-line (A) drugs; Level B = moderate-quality evidence = second-line (B) drugs; Level C = low-quality evidence = third-line (C) drugs; Level U and established as, or possibly or probably ineffective = do not use (no comparable rating in EFNS guidelines). AAN = American Academy of Neurology; AHS = American Headache Society; EFNS = European Federation of Neurological Societies. 938 June 2012
  • 10. ment of guideline quality by the 3 reviewers, the AHS/AAN and the Canadian guidelines were recom- mended for use, while the EFNS guidelines were not. Appendix IV provides the ratings for each compo- nent of the 6 domains. DISCUSSION The 2012 AHS/AAN guidelines for episodic migraine prevention provide a welcome summary of the evidence that underpins commonly used treat- ments for migraine. Most of the drugs deemed to have the highest level of evidence in the 2000 guidelines remain in that category in 2012. Although the methods used to locate and appraise evidence and link it to recommendations varied among the 3 guide- lines we reviewed, there was remarkable consistency in the ratings of drugs for first-line use. In contrast, recommendations diverged substan- tially for gabapentin and feverfew. This divergence is potentially confusing for clinicians and patients.7 It may be related to differences in search strategies or methods for selecting the evidence. In our view, however, it is most likely due to the way in which recommendations were formulated. The AHS/AAN ratings were assigned solely on the basis of an assess- ment of efficacy,while the Canadian and EFNS catego- rizations sought to balance efficacy and side effects. In the case of gabapentin, which is widely believed to be well tolerated, it is therefore not surprising that the Canadian and EFNS guidelines place the drug in their second and third tiers, respectively, while the AHS/ AAN guidelines downgrade the drug because of con- flicting and poor-quality evidence of efficacy. We believe this example points out a serious shortcoming in rating methods that seek to incorpo- rate both benefits and harms. First, although willing- ness to use treatments is influenced by both benefits and harms, ratings assigned by others can never hope to correctly capture the views of different patients. Second, it is well known that potential harm and adverse events are not systematically sought or reported in clinical trials, so that published evidence of harms is likely to be an underestimate.24 And finally, it is questionable whether a drug with low or uncertain efficacy should be recommended for wide- spread use on the basis of tolerability when more effective drugs are available.The quality and credibil- ity of clinical trial evidence for gabapentin has recently been called into considerable question.16,25 This evidence quality problem is better addressed by methods that use a purer approach in generating rec- ommendations, one that is based principally on assessments of efficacy. On the other hand, a pure efficacy-based system of recommendations raises the question of what constitutes a clinically meaningful treatment effect, Table 7.—Overall Assessment and Domain Scores for the 3 Migraine Prevention Clinical Practice Guidelines Using the AGREE-II Instrument AHS/AAN Raw Score (percentage of possible score†) Canadian Raw Score (percentage of possible score†) EFNS Raw Score (percentage of possible score†) Best Possible Score Domain 1: Scope and Purpose 17.6 (84%) 20.7 (99%) 7 (33%) 21 Domain 2: Stakeholder Involvement 6 (29%) 18.3 (87%) 5.3 (25%) 21 Domain 3: Rigor of Development 32 (57%) 52 (93%) 19.6 (35%) 56 Domain 4: Clarity of Presentation 15.6 (74%) 19.3 (92%) 1.3 (6%) 21 Domain 5: Applicability 10 (36%) 24.7 (88%) 5.6 (20%) 28 Domain 6: Editorial Independence 8.3 (59%) 11.3 (81%) 9.6 (69%) 14 Overall Assessment (scale of 1-7) 4.3 (61%) 6 (86%) 2 (29%) 7 Recommended for use? Yes Yes No Yes †Raw score is the average of the scores of 3 independent reviewers, rounded to 1 decimal place. Percentages are rounded to the nearest whole number. AAN = American Academy of Neurology; AGREE-II = Appraisal of Guidelines Research and Evaluation-II; AHS = American Headache Society; EFNS = European Federation of Neurological Societies. Headache 939
  • 11. especially in relation to side effects. Some drugs that have statistically significant evidence of benefit in well-designed and conducted trials may nonetheless provide very marginal benefits when applied to routine clinical practice.An example of this situation is frovatriptan,where the magnitude of clinical benefit is quite small in comparison with treatment burden and cost.26 One compromise might be to present informa- tion about both efficacy and side effects but to refrain from incorporating them in a composite measure.This allows clinicians using the guidelines to individualize treatment decisions based on both efficacy and patient preferences regarding specific risks. The quality of the AHS/AAN and Canadian guidelines, as assessed with the AGREE-II tool, was better than that of guidelines in other specialties, which is heartening.13 Both are recommended for use on the basis of the AGREE-II quality assessment. It is likely that the Canadian guidelines scored particu- larly high on the AGREE measure because they were developed in accordance with AGREE recommenda- tions. In contrast, the EFNS guidelines do not appear to meet widely accepted standards for guideline quality and are not recommended for use. Future efforts are needed to ensure that guide- lines are regularly updated and that guideline devel- opers make use of methods to locate and incorporate unpublished clinical trial evidence.27 There are many reasons that it can be difficult to locate clinical trial evidence. Some have to do with problems in tagging studies as RCTs in MEDLINE or the need to con- dense information to meet word limits imposed by medical journals.28,29 It is clear, however, that much clinical trial evidence has never been published or has been incompletely reported.30 Unfortunately, there is substantial reason to believe that this problem of missing or manipulated evidence affects the clinical evidence when one evaluates migraine therapy.22,31-33 The incorporation of unpublished evidence into meta- analyses has been shown to alter conclusions about treatment efficacy.To ensure the integrity,validity,and credibility of migraine clinical practice guidelines, developers should make strenuous efforts to locate all relevant evidence.34 This and other recommendations for the development of future migraine clinical prac- tice guidelines are listed in Box 1. In summary, the 2012 updated AHS/AAN guide- lines for preventive treatment of episodic migraine provide a welcome and comprehensive overview of the breadth and quality of existing evidence. They Box 1.—Seven recommendations for the development of clinical practice guidelines for migraine treatment. • Ensure that guideline processes conform to authoritative recommendations about ideal guideline development and reporting, such as the Appraisal of Guidelines Research and Evaluation (AGREE) measures • Provide explicit definitions for terms such as “acute” or “preventive/prophylactic” treat- ment • Avoid limiting the initial evidence search to familiar or widely used treatments in order to minimize the chance of missing important new research and developments • Make and document attempts to locate unpublished and missing clinical trial evi- dence, for example by searching the grey lit- erature, manufacturer web sites, and clinical trial registration and reporting sites such as clinicaltrials.gov • Assess trial quality against headache-specific recommendations for outcome measures, quality of adverse event collection and reporting, and trial conduct. See in particular the International Headache Society guide- lines for the conduct of controlled trials of migraine prophylaxis and adverse event reporting in migraine trials • Present separate assessments and recommen- dations regarding the efficacy and side effects of treatments. Avoid the use of composite recommendations that seek to balance effi- cacy and tolerability because the quality and completeness of evidence for side effects is known to be poor • Present and adhere to a timeline for regular updates and modifications to guidelines 940 June 2012
  • 12. confirm the benefits of many widely used therapies, identify drugs that should be avoided, and remind clinicians of emerging evidence for a wide array of newer treatment choices. APPENDIX I: SEARCH STRATEGY MEDLINE Search Strategy: Database: Ovid MEDLINE(R) <1950 to April Week 3 2012> 1. guideline.pt. 2. practice guideline.pt. 3. Health Planning Guidelines/ 4. Consensus Development Conference/ 5. (guideline or guidelines).m_titl. 6. *Clinical Protocols/ 7. or/1-6 8. exp migraine/ 9. “migraine”.tw. 10. or/8-10 11. 7 and 10 12. limit 11 to yr=“2008-Current” Guideline website search strategy: We searched the website of the National Guideline Clearinghouse maintained by the United States Agency for Health Care Quality. The search was conducted at http://www.guideline.gov/search/search.aspx?term= migraine using the keyword “migraine” on April 17, 2012. APPENDIX II: FLOW OF GUIDELINES THROUGH THE REVIEW 5 guidelines, in addition to the AHS/AAN guidelines, met criteria for retrieval17-21 2 additional guidelines retrieved and included in the review20,21 3 excluded * 2 not in English17,18 * 1 not based on systematic review or evidence grading19 Headache 941
  • 13. APPENDIX III: RATINGS OF DRUGS EVALUATED IN ONLY 1 GUIDELINE AHS/AAN Guideline Canadian Guideline EFNS Guideline Acebutolol Possibly not effective Not rated Not rated Acenocoumadin U Not rated Not rated Acetazolamide U Not rated Not rated Atenolol B Not rated Not rated Carbamazepine C Not rated Not rated Clomipramine Probably not effective Not rated Not rated Clonazepam Possibly not effective Not rated Not rated Clonidine C Not rated Not rated Coumadin C Not rated Not rated Cyclandelate U Not rated Not rated Cyproheptadine C Not rated Not rated Estrogen C Not rated Not rated Fenoprofen B Not rated Not rated Fluoxetine U Not rated Not rated Flurbiprofen C Not rated Not rated Fluvoxamine U Not rated Not rated Frovatriptan A Not rated Not rated Guanfacine C Not rated Not rated Histamine SC B Not rated Not rated Hyperbaric oxygen U Not rated Not rated Ibuprofen B Not rated Not rated Indomethacin U Not rated Not rated Ketoprofen B Not rated Not rated Lamotrigine Established as ineffective Not rated Not rated Mefenamic acid C Not rated Not rated Montelukast Probably not effective Not rated Not rated Nabumetone Possibly not effective Not rated Not rated Naproxen sodium B Not rated Not rated Naratriptan B Not rated Not rated Nebivolol C Not rated Not rated Nicardipine U Not rated Not rated Nimodipine U Not rated Not rated Omega 3 U Not rated Not rated Oxcarbazepine Possibly not effective Not rated Not rated Picotamide U Not rated Not rated Pindolol C Not rated Not rated Pitzotifen Not rated Weak, high-quality evidence Not rated Protriptyline U Not rated Not rated Telmisartan Possibly not effective Not rated Not rated Timolol A Not rated Not rated Zolmitriptan B Not rated Not rated 942 June 2012
  • 14. APPENDIXIV:QUALITYOFTHE3MIGRAINEPREVENTIONGUIDELINESFORTHE6DOMAINSOFTHEAGREE-II INSTRUMENT Guideline:AHS/AANCanadianEFNS Itemnumber Averageof3reviewerratings; possiblescoreof7 Domain1:Scopeand Purpose 1.Theoverallobjective(s)oftheguidelineis(are)specificallydescribed. 2.Thehealthquestion(s)coveredbytheguidelineis(are)specificallydescribed.671.7 3.Thepopulation(patients,public,etc)towhomtheguidelineismeanttoapplyisspecificallydescribed.571.7 Domain2: Stakeholder Involvement 4.Theguidelinedevelopmentgroupincludesindividualsfromallrelevantprofessionalgroups. 5.Theviewsandpreferencesofthetargetpopulation(patients,public,etc)havebeensought.151 6.Thetargetusersoftheguidelineareclearlydefined.3.772.3 Domain3:Rigorof Development 7.Systematicmethodswereusedtosearchforevidence. 8.Thecriteriaforselectingtheevidenceareclearlydescribed. 9.Thestrengthsandlimitationsofthebodyofevidenceareclearlydescribed. 10.Themethodsforformulatingtherecommendationsareclearlydescribed. 11.Thehealthbenefits,sideeffects,andriskshavebeenconsideredinformulatingtherecommendations.3.36.72 12.Thereisanexplicitlinkbetweentherecommendationsandthesupportingevidence.6.772 13.Theguidelinehasbeenexternallyreviewedbyexpertspriortoitspublication. 14.Aprocedureforupdatingtheguidelineisprovided.26.35.7 Domain4:Clarityof Presentation 15.Therecommendationsarespecificandunambiguous. 16.Thedifferentoptionsformanagementoftheconditionorhealthissueareclearlypresented.563 17.Keyrecommendationsareeasilyidentifiable.671.7 Domain5: Applicability 18.Theguidelinedescribesfacilitatorsandbarrierstoitsapplication.26.71 19.Theguidelineprovidesadviceand/ortoolsonhowtherecommendationscanbeputintopractice.4.36.71 20.Thepotentialresourceimplicationsofapplyingtherecommendationshavebeenconsidered.2.761 21.Theguidelinepresentsmonitoringand/orauditingcriteria. Domain6:Editorial Independence 22.Theviewsofthefundingbodyhavenotinfluencedtheguideline(explicitstatement).577 23.Competinginterestsofguidelinedevelopmentgroupmembershavebeenrecordedandaddressed. Headache 943
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